Top Line: How should we think about isolated metastases to regional nodes after radical prostatectomy?
The Study: Historically there has been debate as to whether this should be treated as locoregional versus distant disease. Practically, this leads to a debate between local versus systemic therapy. In 2009 the single-arm phase 2 PLATIN trials began enrolling men with post-prostatectomy isolated nodal recurrences without (PLATIN-4, n=40) or with (PLATIN-5, n=39) prior adjuvant/salvage prostate bed radiation. All men received androgen deprivation therapy (ADT) 2 months before, during, and after radiation for a total of 2 years. In PLATIN-4, radiation-naive men received 51 Gy to elective pelvic nodes and a simultaneous integrated boost (SIB) of 61.2 Gy to clinically-involved nodes and 68 Gy to the prostate bed all in 34 fractions. In PLATIN-5, fields were matched to prior prostatectomy bed radiation where men received 46.8 Gy to elective nodes and a SIB of 57.2 Gy to clinically-involved nodes all in 26 fractions. The primary endpoint of grade 3+ toxicity occurred in eight patients: five with lower extremity lymphedema, two with fecal incontinence, and one with persistent gross hematuria. The secondary endpoint of median progression-free survival surpassed 5 years after first salvage radiation in PLATIN-4 (66 months) and 3 years after mostly second salvage radiation in PLATIN-5 (39 months). There were only two in-field recurrences, both at the prostate bed. As the vast majority of failures occurred out-of-field, better patient selection with modern PSMA-PET staging to rule out extra-pelvic disease should only improve outcomes further.
TBL: Salvage radiation to pelvic nodes with a SIB to gross nodes with long course ADT is a safe and effective definitive treatment for isolated nodal recurrence following prostatectomy even after prior prostatectomy bed radiation. | Fink, Int J Radiat Oncol Biol Phys 2024
The Study: Historically there has been debate as to whether this should be treated as locoregional versus distant disease. Practically, this leads to a debate between local versus systemic therapy. In 2009 the single-arm phase 2 PLATIN trials began enrolling men with post-prostatectomy isolated nodal recurrences without (PLATIN-4, n=40) or with (PLATIN-5, n=39) prior adjuvant/salvage prostate bed radiation. All men received androgen deprivation therapy (ADT) 2 months before, during, and after radiation for a total of 2 years. In PLATIN-4, radiation-naive men received 51 Gy to elective pelvic nodes and a simultaneous integrated boost (SIB) of 61.2 Gy to clinically-involved nodes and 68 Gy to the prostate bed all in 34 fractions. In PLATIN-5, fields were matched to prior prostatectomy bed radiation where men received 46.8 Gy to elective nodes and a SIB of 57.2 Gy to clinically-involved nodes all in 26 fractions. The primary endpoint of grade 3+ toxicity occurred in eight patients: five with lower extremity lymphedema, two with fecal incontinence, and one with persistent gross hematuria. The secondary endpoint of median progression-free survival surpassed 5 years after first salvage radiation in PLATIN-4 (66 months) and 3 years after mostly second salvage radiation in PLATIN-5 (39 months). There were only two in-field recurrences, both at the prostate bed. As the vast majority of failures occurred out-of-field, better patient selection with modern PSMA-PET staging to rule out extra-pelvic disease should only improve outcomes further.
TBL: Salvage radiation to pelvic nodes with a SIB to gross nodes with long course ADT is a safe and effective definitive treatment for isolated nodal recurrence following prostatectomy even after prior prostatectomy bed radiation. | Fink, Int J Radiat Oncol Biol Phys 2024